Usefulness of the rendezvous technique for biliary stricture after adult right-lobe living-donor liver transplantation with duct-to-duct anastomosis

Abstract

Background/aims: Replacement of a percutaneous transhepatic biliary drainage (PTBD) catheter with inside stents using endoscopic retrograde cholangiography is difficult in patients with angulated or twisted biliary anastomotic stricture after living donor liver transplantation (LDLT). We evaluated the usefulness and safety of the rendezvous technique for the management of biliary stricture after LDLT.

Methods: Twenty patients with PTBD because of biliary stricture after LDLT with duct-to-duct anastomosis underwent the placement of inside stents using the rendezvous technique.

Results: Inside stents were successfully placed in the 20 patients using the rendezvous technique. The median procedure time was 29.6 (range, 7.5-71.8) minutes. The number of inside stents placed was one in 12 patients and two in eight patients. One mild acute pancreatitis and one acute cholangitis occurred, which improved within a few days. Inside stent related sludge or stone was identified in 12 patients during follow-up. Thirteen patients achieved stent-free status for a median of 281 (range, 70-1,351) days after removal of the inside stents.

Conclusions: The rendezvous technique is a useful and safe method for the replacement of PTBD catheter with inside stent in patients with biliary stricture after LDLT with duct-to-duct anastomosis. The rendezvous technique could be recommended to patients with angulated or twisted strictures.

Keywords: Biliary stricture; Endoscopic retrograde cholangiography; Liver transplantation; Percutaneous transhepatic biliary drainage; Rendezvous.

Fig. 1

Rendezvous technique using a duodenoscope. (A) The PTBD catheter was located over the anastomotic stricture into the duodenum. The angle between the right hepatic duct and the common bile duct was sharp (93°). (B) The 0.035 inch guidewire was inserted through the PTBD catheter, and the PTBD catheter was then removed. (C) The guidewire was noted outside the major ampulla. (D) Endoscopic sphincterotomy was performed along the catheter. (E, F) A bottle-top metal-tip ERC catheter was inserted along the guidewire. (G) An inside stent was placed over the stricture. (H) The distal end of the inside stent was noted at the major ampulla.

Fig. 2

Rendezvous technique using a duodenoscope. (A) A PTBD catheter was located over anastomotic stricture into the duodenum. The angle between the right hepatic duct and the common bile duct was sharp (100°). (B) A 0.035 inch guidewire was inserted through PTBD catheter and the PTBD catheter was then removed. (C) The end of theguidewire was placed outside the ampulla. (D) A bottle-top metal-tip ERC catheter was inserted along the guidewire. (E) Balloon dilatation was performed at the anastomotic stricture. (F) Two inside stents were placed over the stricture in anterior and posterior branches of the right hepatic duct of the recipient's liver.

Fig. 3

Rendezvous technique using a two-channel endoscope. (A) A 0.035 inch guidewire was inserted alongside the PTBD catheter. (B) The end of the guidewire was placed outside the ampulla. (C) Because the duodenoscope failed to pass through the pyloric ring, a two-channel endoscope was introduced. The tip of the endoscope was bent nearly 180° to pass over the pyloric ring. (D) The guidewire was captured into the two-channel endoscope, and a bottle-top metal-tip ERC catheter was introduced along the guidewire. (E) An inside stent was placed over the stricture. (F) The distal end of the inside stent was noted at the ampulla.